5Trends in Childhood Mortality

Althea Hill

INTRODUCTION

A broad, comparative outline of levels, patterns, and trends in childhood mortality across the African continent was presented in a paper written in 1987 and published recently (Hill, 1989, 1991, 1992). That paper covered sub-Saharan mainland Africa between roughly the late 1940s and the late 1970s and made use of all the data on child survival available at the time of writing. The overall findings are summarized in Figures 5–1 and 5–2, which display summary estimates over time for all countries possessing usable data.

Four major features, all clearly visible in the figures, emerged from the findings of that paper. These were

declines in childhood mortality since World War II in almost all countries for which data were available;

much variation among countries in the type of decline;

much variation among countries in the level of childhood mortality in all periods; and

a marked overall difference in mortality levels between countries in western and middle Africa and countries in eastern and southern Africa,

Althea Hill is at the India Country Department, Population and Human Resources Division, The World Bank.

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Demographic Change in Sub-Saharan Africa
5
Trends in Childhood Mortality
Althea Hill
INTRODUCTION
A broad, comparative outline of levels, patterns, and trends in childhood mortality across the African continent was presented in a paper written in 1987 and published recently (Hill, 1989, 1991, 1992). That paper covered sub-Saharan mainland Africa between roughly the late 1940s and the late 1970s and made use of all the data on child survival available at the time of writing. The overall findings are summarized in Figures 5–1 and 5–2, which display summary estimates over time for all countries possessing usable data.
Four major features, all clearly visible in the figures, emerged from the findings of that paper. These were
declines in childhood mortality since World War II in almost all countries for which data were available;
much variation among countries in the type of decline;
much variation among countries in the level of childhood mortality in all periods; and
a marked overall difference in mortality levels between countries in western and middle Africa and countries in eastern and southern Africa,
Althea Hill is at the India Country Department, Population and Human Resources Division, The World Bank.

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Demographic Change in Sub-Saharan Africa
FIGURE 5–1 Risk of dying before age 5, western and middle Africa, 1926–1980. SOURCE: Hill (1991: Figure 3–2).
with a rough gradient running from higher mortality in the northwest to lower mortality in the southeast of the continent.
With regard to this last point, there were indications that this gradient, having been very distinct at the start of the period of study, was becoming progressively blurred as more and more western and middle African countries reduced their mortality levels to near or within the eastern and southern range. However, the picture was still too indefinite for firm conclusions at that time.
The paper also noted three exceptions to these general patterns:
Some countries had experienced periods of static or rising mortality, almost all against a background of civil war and disruption of normal socioeconomic development (e.g., Ethiopia, Mozambique, Rwanda, and Sudan).
The mortality of a few western and middle African countries (notably Ghana, Congo, and Cameroon) had fallen to well within the eastern and southern range.
One eastern African country, Malawi, had a level of mortality toward the upper end of the western and middle African range.

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Demographic Change in Sub-Saharan Africa
FIGURE 5–2 Risk of dying before age 5, eastern and southern Africa and Sudan, 1926–1980. SOURCE: Hill (1991: Figure 3–3).
DATA DEVELOPMENTS SINCE 1987
In 1987, when the aforementioned review of levels and trends in childhood mortality in Africa was prepared, almost no data on developments in the 1980s were yet available. As shown in Table 5–1, several censuses and surveys had indeed been carried out between 1980 and 1987, but very few of them had yet yielded available results. Over the last five years, however, a considerable quantity—though by no means all—of new data collected during the 1980s has been released. This chapter reviews levels and trends in many of the countries for which fresh data are available for analysis, and examines whether the conclusions of the previous review still hold both at country and at continental levels.
In total, new national-level data are available for 16 countries (about 40 percent of all mainland sub-Saharan countries); these are Botswana, Burkina Faso, Burundi, Côte d’Ivoire, The Gambia, Ghana, Kenya, Liberia, Malawi, Mali, Nigeria, Senegal, Sudan, Togo, Zaire, and Zimbabwe. Data are also available for a large part of Uganda. In addition, data from small-

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Demographic Change in Sub-Saharan Africa
Country
Type of Operationa
Date
Status of Mortality Data
WFS typeb,c
1984
Published
Census
1987
Partly available
Mozambique
Censusb
1980
Available
WFS typeb,c,e
1987
Partly available
Rwanda
WFS typec
1983
Published
Somalia
Demographic survey
1980
Published
Census
1986–1987
Possibly lost
Tanzania
Census
1988
Partly available
Uganda
Census
1980
Mostly lost
DHS (south only)b
1988–1989
Published
Zambia
Census
1980
Not published
DHS
1992
Partly available
Zimbabwe
Censusb
1982
Partly published
CPSb
1984
Published
Demographic surveyb
1987
Partly published
DHSb
1988
Published
Southern
Botswana
Censusb
1981
Published
CPSb
1984
Published
Demographic survey
1987
Not yet available
DHSb
1988
Published
Lesotho
Census
1986
Not yet available
Swaziland
Census
1986
Not yet available
DHS typed
1986
Not yet available
Northern
Sudan
Censusb
1983
Available
DHS (northern only)b
1989–1990
Published
aWFS: World Fertility Survey; LSMS: Living Standards Measurement Survey; DHS: Demographic and Health Survey; CPS: Contraceptive Prevalence Survey.
bData set used in this chapter.
cSurvey modeled after WFS, but not part of the WFS series.
dSurvey modeled after DHS, but not part of the DHS series.
eData from Maputo, the capital city, are used here.
scale surveys in Mozambique and Angola are examined, because of the particular interest and data scarcity in those two countries.
The methodology employed is the same as for the previous review (see appendix A to this chapter). The mainstay of the analysis is information on child survival, collected from mothers in censuses and surveys and analyzed by using the Trussell variant of the Brass child survival method (Trussell, 1975); estimates based on Coale-Demeny North and South families of life tables (Coale and Demeny, 1983) are compared, and those that appear to fit

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Demographic Change in Sub-Saharan Africa
Summary estimates of dying before age 5 (per 1,000), selected African countries between 1979 and 1985.
the data best are selected.1 Direct data on child deaths from maternity histories are used for evaluation but not for the final estimates. More methodological details are given in Hill (1989, 1991, 1992).
1
Coale and Demeny developed four model life table families (East, West, North, and South) to reflect the different age and sex patterns of mortality derived from historical data from eastern-central, northwestern, Scandinavian, and southern countries of Europe, respectively. The North and South models provide the best fit for the African age pattern of mortality in childhood (see the appendix to this chapter for details). Estimates based on these two models are given in the appendix B tables for each country discussed. In some cases, the estimates from both models are also presented in the figures; however, because of space limitation, only one of the models is usually presented in a figure.

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Every stage of the analysis and estimation for each country is standardized as much as possible in order to put individual country results into a framework of continental levels, patterns, and trends. Inevitably, estimation from large quantities of imperfect data is a subjective process in which individual judgment must play a large part. (See map for summary of continental levels of child mortality.)
NEW COUNTRY DATA AND RESULTS
Botswana and Zimbabwe
These two countries are examined together because they are neighbors, their levels of overall development are very similar, their mortality levels and trends were also very similar up to 1980 (see Figure 5–2), and their data collection schedules in the 1980s were almost identical. They each had a census at the beginning of the decade, a Contraceptive Prevalence Survey (CPS) in 1984, an intercensal demographic survey (ICDS) in 1987 (unfortunately not yet available for Botswana), and a Demographic and Health Survey (DHS) in 1988.
The results of the analysis of all available mortality data for both countries are presented in Tables 5–B.1 and 5–B.2 of appendix B, and are shown graphically in Figures 5–3, 5–4, and 5–5. In both, there is a marked contrast between the smoothness and regularity of the census results and the irregular, seesaw, and often rather wild results from various surveys; no doubt the much larger numbers available for analysis from the census are largely responsible. However, the consistency and plausibility of the results from the 1980s survey data differ sharply between the two countries.
For Botswana, provided the South model is used, all the data except the direct DHS reports are highly consistent. They show a continued decline in childhood mortality from 1955 to 1985, with the decline possibly accelerating during the late 1970s and early 1980s. Because Botswana enjoyed rapid economic growth and fast-developing infrastructure and social services throughout the 1970s and 1980s, such a trend is not at all surprising. The very low level of mortality achieved by the mid-1980s—a probability of dying by age 5 of not much more than .050, which implies an infant mortality rate between 30 and 40 deaths per 1,000 live births—should also be acceptable because the DHS shows that child health and nutrition are excellent. Botswana appears now to have perhaps the lowest mortality in sub-Saharan Africa.
By contrast, the 1980s survey data for Zimbabwe are confused and inconsistent, with the exception of the larger-scale 1987 demographic survey of the traditional type, which fits well with the two sets of census data. The 1984 CPS results not only are highly irregular in trend—first steeply up

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Demographic Change in Sub-Saharan Africa
FIGURE 5–5 Risk of dying before age 5, Zimbabwe, 1950–1990, South model. SOURCES: 1969 census (Rhodesia, n.d.); 1982 census (Zimbabwe, 1985a); 1984 Contraceptive Prevalence Survey (CPS) (Zimbabwe, 1985b); 1987 Intercensal Demographic Survey (ICDS) (Zimbabwe, 1991); 1988 Demographic and Health Survey (DHS) (Zimbabwe, 1989).
and then even more steeply down, all in the space of less than 15 years—but appear quite at odds with all the other data. The 1988 DHS mortality levels are much too low compared with the other data sources, except perhaps in the most recent few years. The best choice seems to be a combination of the 1987 demographic survey results with those of the two censuses, which would also yield mortality levels similar to those from the DHS around the mid-1980s. North appears the better-fitting model for the two censuses, but South gives better consistency thereafter; there seems no clear-cut reason to prefer one over the other.
The resulting trend is again of a continued mortality decline from the early 1970s to the mid-1980s, gentle at first, then with perhaps an acceleration of decline in the 1980s; there is also a hint in the data of some temporary stagnation or rise in mortality during the late 1970s, the period of the war for independence. The relatively low overall level of childhood mortality achieved by the mid-1980s—a probability of dying by age 5 of about .080 to .090—is again consistent with Zimbabwe’s good general level of income and development and the excellent child health and nutrition noted in the DHS. Such a level would place Zimbabwe behind Botswana, but still among the very lowest-mortality countries in Africa.

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Demographic Change in Sub-Saharan Africa
Middle and Eastern Africa
Mozambique and Angola, the two major former Portuguese colonies, have enjoyed neither stability nor solid economic growth for many years. In both, a long and painful war for independence was followed by a short period of relative peace before internal conflicts resumed. No new national-level data for the 1980s are yet available for Mozambique, and none were collected in Angola. Survey data from two small areas in the southern parts of these countries are, however, available and are presented in this chapter. These are Maputo, the capital city of Mozambique (data from a 1987 national World Fertility Survey (WFS) type of survey), and rural parts of the southwest region of Angola bordering on Namibia (data from a local socioeconomic-demographic survey in 1988). The results from these new data sets, combined with the latest available national data, are shown in Tables 5–B.3 and 5–B.4, and summarized graphically in Figures 5–6 and 5–7.
The trend in childhood mortality in Maputo between the early 1970s and the mid-1980s is broadly consistent with the picture already evident in the national census results. There was possibly a mortality decline through the earlier 1970s (when the Portuguese were still developing Maputo as a modern city headquarters containing a major concentration of the Portuguese settler population), followed by stagnation from the mid-1970s through
FIGURE 5–6 Risk of dying before age 5, Mozambique and Maputo, 1960–1990, North and South models. SOURCES: 1980 census (Mozambique, n.d.); 1987 Maputo Fertility Survey (MFS) (WFS-type survey) (Mozambique, 1987).

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FIGURE 5–7 Risk of dying before age 5, Angola and southwestern Angola, North and South models. SOURCES: 1940 census (Heisel, 1968); 1988 rural survey (Angola, 1990).
the mid-1980s, during which the Portuguese withdrawal was followed by the onset of a crippling civil war. The overall level of childhood mortality in Maputo during the late 1970s and 1980s was, however, relatively low, with a probability of dying by age 5 of .120 to .140—much lower than the corresponding level of .270 to .280 for Mozambique as a whole.
The picture in southwestern Angola is even worse. Rural pastoral and agricultural populations appear to have experienced stagnating or rising childhood mortality from 1970 to the mid-1980s, even though this area was relatively prosperous and least affected by the postindependence civil war. According to the analysis of the 1940 census reported in Brass et al. (1968), the region, then called Huila, enjoyed by far the lowest childhood mortality in Angola at that time. The childhood mortality estimates emerging from the 1988 rural survey, with probabilities of dying by age 5 of .200 to .250, represent an improvement over the levels found in the 1940 census data, but are still very high given the area’s location in the lowest-mortality part of Africa.
Full results from the Malawi census of 1987 are not yet available. However, given Malawi’s extraordinarily severe childhood mortality in earlier periods—probabilities of dying by age 5 of .330 to .370, which are high for any part of sub-Saharan Africa (see Figures 5–1 and 5–2) —it is of interest to examine the additional data on trends from the mid-1960s to the beginning of the 1980s that emerge from the two surveys carried out in

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